Behavior Consult History Form

2504 Mall Drive Eau Claire, WI 54701 715-835-5011

Behavior Consult History Form
There is no judgement being passed based on any of your answers. This is simply to help us get the most information to best help you and your pet.

* Indicates required field

Client's Name *

First

Last

Secondary Name: *

Phone Number: *

Patient information:

Pet's Name *

Gender: *

Male Female Neutered Male Spayed Female

Species: *

Dog Cat

Breed: *

Medical History:

When was last physical exam: *

Have there been any medical/health concerns since then? If yes, please describe: *

Are vaccinations including rabies current? *

Yes No

List any medications your pet is taking including any vitamins or supplements: *

Does you pet have any pre-existing or current medical problems? If yes, please describe: *

Has your pet ever had a seizure? If yes, please provide more information-how many, how frequently, require any medical treatment? *

List any medications, supplements, collars, etc that have been used for treatment of the behavioral problem: *

Upload patient records *

Max file size: 20MB

Household information:

Please list all members of the household with gender, age, relationship to you, and how they get along with the pet: *

Please list all household pets, including species, breed, gender, age, age acquired, and how they get along with the pet: *

Background information:

How old was your pet when you first acquired him/her? *

Where did you acquire this pet? *

Why did you get this pet (family pet, hunting, breeding, protection, other)? *

Have you had other dogs before? *

Yes No

This breed? *

Yes No

Other cats? *

Yes No

Describe your pet as a puppy/kitten: *

Was there an age/event that seemed to change your pet's behavior? *

When you are not home where is your pet (free roaming, kennel, specific room, other)? *

How many times per day is your pet walked? *

For how many minutes each time? *

Who walks your pet? *

What type of collar/leash do you use? *

What other types of exercise does your pet engage in? *

Do you play with your pet routinely? Type of toys, etc used: *

What is your living situation (house, apartment, yard size)? *

Is your pet allowed on the furniture? *

How is your pet fed (meal fed, free choice, limited amount free choice, what type of bowl)? *

Describe how you prepare to leave the house when the pet will be left alone: *

Has there been any change in your pet's attitude or energy level? If yes, when did it start? Is it worsening, staying the same? *

Has there been any change in your pet's appetite? If yes, when did it start? Is it worsening, staying the same? *

Have there been any changes in the household? Move to new home, recent visits, remodeling, etc? *

Have there been any changes in your pet's mobility? Any stiffness, any changes to how using stairs, jumping on furniture/counters, etc? If yes, when did it start? Is it worsening? *

For dogs only:

What is your dog's training class history? Which trainer did you use? *

What commands does your dog know? *

Is your dog trained to go back to a certain spot/location (like a bed or crate)? How reliable is the response? *

For cats only:

How many litter boxes do you own? *

Describe the litter boxes (open, covered, liner, etc): *

What type of litter do you use (clumping, scented, wheat, etc)? *

Where are the boxes located (closet, which room)? *

How many floors to your house? *

How many cats in the house? *

Is your cat declawed? *

Yes No

Does your cat use a scratching post? *

Yes No

Does your cat have any outside access? If yes, describe (on leash, in fenced yard, catio, other): *

Behavioral problem:

Please list the problem(s) you wish to address including the seriousness, when it first occurred, and the frequency of the problem: *

Describe a typical episode of the problem(s): *

Has the frequency of the behavior: *

increased decreased remained unchanged

Has the intensity of the behavior: *

increased decreased remained unchanged

Have there been any changes in the household (new pet or family member, move, etc): *

What have you tried to changed the problem behavior(s)? Have they been useful? *

Have you considered or are you considering rehoming your pet? *

Yes No

Have you considered or are you considering euthanasia for your pet? *

Yes No

Is there any other information you think would be helpful? *

Submit

Helpful info

Office hours

Monday 8:00 am to 5:00 pm
Tuesday 8:00 am to 5:00 pm
Wednesday 8:00 am to 5:00 pm
Thursday 8:00 am to 5:00 pm
Friday 8:00 am to 5:00 pm
Saturday 8:00 am to 12:00 pm
Sunday Closed

Boarding release- Sat & Sun from 4-4:30 pm

Get in touch

Address: 2504 Mall Drive, Eau Claire, WI 54701

Phone: 715-835-5011
Fax: 715-835-0993

Email: info@ecanimalhospital.com